Scrotal Pain Flashcards
Testis (Testicle)
Responsible for production of sperm and androgens (testosterone)
Ovoid structure measuring 3-5 cm
One testis may be slightly larger and one testis (usually the left) with hang slightly lower
Tunica vaginalis
Fascial layer that encapsulates the anterior 2/3 of the testis
Location for potential fluid accumulation
Epididymis
Tightly coiled, spongy, tubular structure located on the posterior aspect and running from a superior to inferior pole
Aids in the storage and transport of sperm cells
Facilitates sperm maturation
Spermatic cord
Consists of the vas deferens and testicular blood vessels
Transverses into the retropubic space
Urgent Medical or Surgical Intervention
Localized scrotal pain
Testicular appendiceal torsion
Acute epididymitis
Diffuse scrotal pain
Testicular torsion
Acute epididymo-orchitis or acute orchitis
Fournier’s gangrene (necrotizing fasciitis of the perineum)
Nature and timing of the onset of pain, specific location of pain, fever and/or lower urinary tract symptoms should be noted
Prior inguinal or scrotal surgery
Complete examination of the abdomen, inguinal region, scrotal contents and skin
Cremasteric reflex testing
Testicular Appendiceal Torsion
general
Appendix testis
Small (0.3 cm) pedunculated structure on the anterosuperior aspect of the testis
Represents an embryologic remnant of the müllerian duct system
Has no function
Predisposed to torsion (twisting) during childhood (7-14 years)
Mimic of testicular torsion
Onset of pain is usually more gradual
Pain is localized to the anterosuperior testis
“blue dot sign”
Bluish discoloration visible through the skin in the upper pole
Testicular Appendiceal Torsion
Tx
Rest
Avoid activities that cause pain or soreness
Ice
Apply an ice pack or cold pack to the area for 10–20 minutes at a time
Elevation
Position the patient to take pressure off your scrotum and testicles
Pain medication
Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for pain and swelling
Support
Wear snug underwear or compression shorts to support the area
Acute Epididymitis
general and likely pathogens
Most common cause of scrotal pain in adults
> 600,000 cases per year in the United States
>
Etiology
Infectious
Men < 35 years of age
Associated with urethritis due to Neisseria gonorrhoeae or Chlamydia trachomatis
Less common organisms: Ureaplasma species and Mycoplasma genitalium
Men > 35 years of age
Associated with UTI and prostatitis due to enteric gram-negative bacteria (Escherichia coli andPseudomonas)
Non-infectious
Trauma
Auto-immune diseases
Men of any age who engage in insertive anal intercourse are at increased risk for acute bacterial epididymitis
Acute Epididymitis
Dx
Diagnosis
Made presumptively based on the history and physical examination
Testing
Urinalysis
Urine culture
Testing for gonorrhea and chlamydia (NAAT)
Acute Epididymitis
Tx
Treatment
Acutely ill patients may require admission for IV antibiotics and IV hydration
Most patients can be managed on an outpatient basis
Scrotal elevation
Ice
NSAIDs
Antibiotics
Empiric antibiotic treatment while awaiting test results
< 35 years and at risk for STI → coverage for gonorrhea and chlamydia (see next slide)
> 35 years and low risk for STI → coverage for enteric pathogens
Ciprofloxacin 500 mg PO twice daily x 10 days or levofloxacin 500 mg PO daily x 10 days
Trimethoprim-sulfamethoxazole (Bactrim) double-strength tablet PO twice daily x 10 days
Patients of any age who practice insertive anal intercourse
Coverage for gonorrhea, chlamydia, and enteric pathogens
Failure to improve within 48-72 hours of starting antibiotic therapy
Obtain scrotal ultrasound
Referral to urology
Acute Epididymitis
Clin man
Localized testicular pain (posteriorly) with tenderness and swelling on palpation
Scrotal wall erythema and swelling
Reactive hydrocele
Fluid collection between the parietal and visceral layers of the tunica vaginalis
Prehn sign (+)
Relief of pain with lifting of the affected testicle
Cremasteric reflex (+)
Stroke/poke inner thigh, and testicle is pulled up. 0.5cm is positive sign
Severe infection
Fever
Rigors
Lower urinary tract symptoms (frequency, urgency, and dysuria)
Gonorrhea & Chlamydia Treatment
Gonorrhea
Single-agent therapy with ceftriaxone (Rocephin) is the preferred regimen
500 mg IM once (individuals who weigh < 150 kg)
1,000 mg IM once (individuals who weigh ≥ 150 kg)
Chlamydia
First-line therapy
Doxycycline 100 mg twice daily for 7 days
Acute orchitis
General and etiology
Inflammation of one or both testicles
Etiology
Bacterial
Most commonly due to sexually transmitted infection (STI)
May be associated with epididymitis
Viral
Mumps virus
1/3 of males with mumps after puberty develop orchitis
Bilateral involvement in up to 30% of cases
Idiopathic
Acute orchitis
Clin man
Testicular pain
N/V
Swelling of one or both testicles
Malaise
Mumps: Headaches, parotid swelling
fever
Note that “testicular pain” and “groin pain” are not interchangeably; groin pain occurs in the fold of skin between the thigh and abdomen — not in the testicle
Acute orchitis
Dx and testing
Diagnosis
Made presumptively based on the history and physical examination
Testing
Urinalysis
Urine culture
Testing for gonorrhea and chlamydia (NAAT)
Scrotal ultrasound
Acute orchitis
Tx
Treatment
Acutely ill patients may require admission for IV antibiotics and IV hydration
Most patients can be managed on an outpatient basis
Scrotal elevation
Ice
NSAIDs
Follow the same empiric antibiotic treatment guidelines as epididymitis
Testicular Torsion
General
Time frames
Twisting of the testicle on the spermatic cord leading to blockage of blood flow to the testicle → necrosis
Urologic emergency
Goal is treatment within 6 hours
Irreversible damage after 8 hours
More common in neonates and post-pubertal boys than adults
Cryptorchidismincreases the risk of testicular torsion
Causes
Inadequate fixation of the lower pole of the testis to the tunica vaginalis
Inciting event (trauma, physical activity)
Spontaneous
Testicular Torsion
clin man
Abrupt onset of moderate-severe diffuse testicular pain
Significant testicular swelling
Reactive hydrocele
Asymmetric high-riding testis with the long axis orientated transversely
Bell clapper deformity
Overlying erythema of the scrotal wall (12-24 hours after the onset of symptoms)
Nausea and vomiting
Diffuse lower abdominal pain
Cremasteric reflex (-)
Prehn sign (-)
No improvement or worsening pain with lifting of the affected testicle
Relief of pain with detorsion
Testicular torsion
Manual Detorsion
If surgery is delayed, an attempt to detorse the testicle manually is warranted
Testis usually rotates medially during torsion
“open book” maneuver
Detorse the testis by rotating the testis outward toward the thigh
Left → rotate clockwise
Right → rotate counter-clockwise
Successful detorsion
Relief of pain
Conversion of the transverse lie of the testis to a longitudinal orientation
Lower position of the testis in the scrotum
Return of normal arterial pulsations on color Doppler ultrasound
Fournier’s gangrene
General
Necrotizing fasciitis of the perineum often involving the scrotum
Caused by a mixed aerobic/anaerobic infection
E. coli,Klebsiella, enterococci along with anaerobes (Bacteroides,Fusobacterium,Clostridium)
Typically seen in:
Diabetic patients
Patients with indwelling catheters
Patients with urethral trauma and urinary tract infection
Patients that are immunocompromised
Fournier’s gangrene
clin man
Severe pain of the lower abdominal wall that spreads to include the groin and scrotum
Significant edema outside the involved skin
Foul odor from the affected skin
Crepitus with palpation of the affected area
Involved area may have vesicles/bullae
Fever
Tachycardia
Hypotension
